This project proposes analyses of access to and outcomes of care for HIV, building on the HCSUS study, which enrolled a probability sample of adults receiving care for HIV in the 48 contiguous United States in early 1996. The nature of the cohort allows weighting of results to produce unbiased estimates of phenomena in the reference population. Dramatic advances in HIV therapeutics have made long-term survival possible. The current proposal takes advantage of the longitudinal nature of the study, and its fielding at the time when new treatments were coming on line, to assess their dissemination and the impact of the pattern of dissemination on health outcomes. The first Aim assesses factors associated with access to and utilization of services, building on determinants in the behavioral model. We will examine changes over time in disparities, demographic differences, and the role of predisposing, enabling and need factors in explaining disparities. Specific analyses include relationship of unmet need for nonmedical service to receipt of treatments, patterns of access by race within exposure groups, impact of acculturation on care of Latinos, access issues for women, and the relationship between patterns of ambulatory care and receipt of medications. The second Aim examines the course of health-related quality of life (HRQOL), symptoms, social support and coping among the HIV population in care. Specific analyses include trajectories of physical and role functioning and of mental health status, the relationship of coping and social support to HRQOL and receipt of therapy over time, trajectories of HRQOL in different demographic subgroups, and evaluation of alternative methods for analyzing change in HRQOL in an HIV population. The third Aim studies outcomes of HIV care. Analyses include impact of pattern of access to and use of services on mortality (to be ascertained through early 2000), decline in immune status, viral load, preventable infections, preventable hospitalizations and HRQOL, the relationship of pattern of opportunistic infection prophylaxis to outcomes, the impact of unmet need for supportive services on outcome, and the impact of competing demands on outcomes. The fourth Aim proposes the first analyses of new surveys of care sites and principal medical providers for HCSUS subjects. Analyses will include characterization of the national sample of providers (training, expertise, patient volume), the relationships of characteristics of sties and physician training, experience, and knowledge to quality of care, and relationship of structure, financial, administrative and normative influence to patient reports about care and to clinical outcomes. The series of products should provide an accurate picture of the factors that need to be addressed to optimize access, processes and outcomes of care for HIV.